Abstract

Introduction

According to a 2007 Institute of Medicine report, “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national healthcare system.”^1(p13) Pharmaceuticals that act in the central nervous system (CNS) are often used to treat psychiatric and neurologic disorders. These medications are among the most frequently used pharmaceuticals comprising 47 of the top 200 most commonly used medications in 2019.² The CNS medications have demonstrated benefit but also are associated with many complexities, including adverse effects, drug interactions, and frequent necessity of lifelong use that often require careful management to improve patient outcomes, including symptom control and need for hospitalization.

People with severe and persistent mental illness often have multiple co-occurring illnesses, receive inadequate health care, and have poor medication and therapeutic outcomes.^3-7 A Center for Healthcare Strategies analysis³ shows that Medicaid patients with co-occurring mental illness or substance use disorder (SUD) were 4 to 5 times more likely to be hospitalized than those without. Further, patients with chronic physical health conditions and a concomitant mental illness or SUD experienced 60% to 70% higher health care costs compared to those without a comorbid mental illness.³ The Center for Healthcare Strategies group³ offers several potential solutions to address the needs of this complex patient population, including the use of multidisciplinary teams, integrated care for physical and behavioral health needs, and financial incentives to care integration.

Patients with neurologic disorders also have complex medication-related needs. People with epilepsy often are unable to reach freedom from seizures and are subject to premature mortality, often from potentially preventable causes, despite pharmacologic treatment.⁸ The global burden of Parkinson disease has steadily grown in recent decades, and patients affected by it experience poor quality of life, frequent hospitalizations, and uncontrolled symptoms despite treatment.^9,10 Overall, there is need for enhancements and optimization in care and medication use for people with psychiatric and neurologic disorders.

Pharmacists with specialized training and experience in the use and management of CNS medications may be well positioned to optimize use of these medications to improve outcomes in patients with psychiatric or neurologic disorders. A psychiatric pharmacist has specialized experience and training related to psychiatric and neurologic disorders and the use of medications for treatment of patients with these conditions. The most validated way to be recognized as a psychiatric pharmacist is certification by the Board of Pharmacy Specialties (BPS) as a board-certified psychiatric pharmacist (BCPP).¹¹ To earn board certification, an applicant must be a graduate of an accredited pharmacy program, have a current active license to practice pharmacy, meet experience and training standards (2 to 4 years of postgraduate training and experience) and pass the BCPP examination. There is not a stand-alone board certification for a neurologic pharmacist. Other certifications issued by BPS (eg, board-certified pharmacotherapy specialist [BCPS], board-certified ambulatory care pharmacist [BCACP], board-certified critical care pharmacist [BCCCP]) include brief review content and examination items on neurologic and psychiatric disorders and their treatments.^11-14 Although pharmacists with other BPS certifications aside from the BCPP do not focus extensively on CNS medications, they do receive additional training pertaining to CNS medications and have certified their ability to manage complex pharmacotherapy regimens, which may include CNS medications. BCPP preparation and examination materials also contain a more extensive neurologic focus than any of the other certification areas offered by BPS, including focused review of epilepsy, Parkinson disease, and headache.¹⁵ There is a significant degree of overlap between treatments and even symptoms of psychiatric and neurologic disorders¹⁶ such that expertise with regard to CNS medications often crosses over between what may typically be considered neurology and psychiatry. Some pharmacists further subspecialize in the treatment of specific psychiatric or neurologic disorders or work in specialty treatment settings. However, there is little available information about training or experience associated with subspecializations such as these. Some pharmacists have approached psychiatric pharmacist designation by practicing with a significant focus on CNS medications and patients with psychiatric and neurologic disorders but have not obtained BPS certification.^17,18 Since 1998, the College of Psychiatric and Neurologic Pharmacists (CPNP) has served as a professional association supporting the education, training, and development needs of pharmacists serving persons with mental illness, SUD, and neurologic disorders and as of April 2020 had more than 2900 members.^19,20 From this point forward, due to the significant overlap in expertise and for brevity, we refer to psychiatric and neurologic pharmacists and/or pharmacists focusing on the use of CNS medications as psychiatric pharmacists.

In 2005, Goldstone and colleagues²¹ selectively reviewed 28 key studies (date range 1978-2014) and highlighted the value of psychiatric pharmacists as part of the health care team improving medication-related outcomes. Goldstone and colleagues conclude that the clinical and financial benefit of psychiatric pharmacist inclusion within an interdisciplinary team for treatment of psychiatric and neurologic disorders is supported in clinical research studies. They issue a call to action “aimed at ensuring all patients with psychiatric or neurologic disorders have access to a standardized, consistent patient care process…provided by a psychiatric pharmacist working as a member of the healthcare team…”^22(p13) while also acknowledging the importance of conducting additional studies and collecting outcome data related to the impact of psychiatric pharmacists on patient care. The current article provides an update summarizing the most recent published evidence regarding the impact of practicing psychiatric pharmacists on patient outcomes in various health care settings.

Methods

A list of relevant base search terms was generated by the authors, and it included psychiatric pharmacy, clinical pharmacy, clinical pharmacy specialist, pharmacy, pharmacist, advanced practice provider, collaborative practice, mental health, and behavioral health. A list of disease-state terms associated with all categories of major mental disorders and a selection of major neurologic disorders that have psychiatric manifestations and are primarily or secondarily treated with CNS medications was also generated (Table 1). Pain conditions were not included. Terms were searched in combinations of base terms and disease-state terms in Google Scholar and PubMed with date limits of January 1, 2014, to June 1, 2019. The authors screened the abstracts of the initial results for each set of search terms and collected potentially relevant articles while excluding those that were published in a language other than English; did not describe an active interventional role of a pharmacist; described training exercises, simulations, technician roles, or changes in perceptions/attitudes; were limited to an economics evaluation, commentary, or feasibility study; were published only in abstract or poster form; or described a role of a pharmacist but did not include either a CNS medication, a psychiatric/neurologic disease, or a psychiatric/neurologic pharmacist. Full-text articles were obtained after initial screening. Two authors (C.C. and A.W.) further evaluated each of these articles and excluded review articles, process descriptions without reported outcomes, articles that did not describe a clinical role of a pharmacist (defined as providing active, direct patient care,²² team-based interventions, and/or population-based care improvements), and articles that only reported numbers or types of pharmacist interventions without associated patient-level outcomes (defined as assessing the benefits/harms directly associated with the patient). A psychiatric pharmacist was defined as any pharmacist with the BCPP certification as well as those pharmacists working in a psychiatry/neurology treatment setting, working with patients with psychiatric/neurologic disorder(s), and/or working with a focus on CNS medication(s). After removal of duplicates, 64 articles were included and are summarized in Table 2. Articles were gathered a priori by health care setting sections to match those utilized by Goldstone and colleagues²¹ in their prior review. Specific verbiage about the treatment settings listed in Table 2 reflects each study authors' characterization of the setting. To determine the presence of BCPP, other board certification(s), or additional training in psychiatric/neurologic disorders or advanced clinical pharmacy practice, we reviewed the author information included in each article and searched the BPS credential verification database²³ for surnames(s) of all authors of included articles as well as the websites of authors' affiliated institutions for information about training and credentials.

TABLE 1 Disease-state search terms

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TABLE 2 Psychiatric pharmacist patient-level impact across patient care settings^a

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TABLE 2 Psychiatric pharmacist patient-level impact across patient care settings^a

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Findings

Psychiatric pharmacists improve patients' treatment outcomes in a variety of health care settings. Hospitalized patients experience fewer medication errors and reductions in repeat hospitalizations as a result of psychiatric pharmacists' involvement.^30,38,39,68 Outpatients in primary care, general mental health, and specialty clinics have improved medication safety (eg, reduction in anticholinergic burden, improved medication appropriateness) and reach therapeutic goals (eg, symptom reduction, fewer hospitalizations) at a higher rate when a pharmacist who is focused on CNS medications contributes to their care.^{47,49,52,54,60,64,65} Patients filling prescriptions in community pharmacies have better access to long-acting injectable antipsychotic medications and increased medication adherence and are more satisfied with their medications when receiving pharmacist-delivered, psychiatry-focused interventions.^83-86 Patients seeking care for SUD experience increased access to buprenorphine-naloxone and naloxone, both life-saving medications, when a psychiatric pharmacist is involved in the SUD care setting.^70,73,74 According to the literature reviewed, there is evidence to suggest that having a psychiatric pharmacist on the health care team improves patient outcomes across a wide variety of inpatient and outpatient settings from general practice to specialized services.

The published literature documents a wide array of services performed by pharmacists focusing on psychiatric and neurologic disease that leads to improvements in patient-level outcomes. Care interventions that include input of pharmacists' expertise into the interprofessional health care team are the most frequently described among the articles that met our search criteria. Joint decision making about medication treatment between psychiatric/neurologic pharmacists, prescribers, and other members of the health care team, leads to statistically significant improvements in disease outcomes and/or medication appropriateness in 22 of 27 studies that described this approach.^* Some of the studies are underpowered to detect a difference and do not show statistically significant outcomes.^{31,33,56,69,70,72} Psychiatric pharmacists also show statistically significant benefits on patient-level outcomes in at least 5 peer-reviewed publications by providing services, including medication reviews,^† patient education,^‡ patient and/or data evaluation for medication safety and efficacy,^{26,31,35,37,40,41,47} and independent management of medication therapy upon referral.^50,76-79,81

Twenty (31.3%) of the included studies have at least 1 BCPP author with formal advanced training in psychiatry/neurology. Eighteen (28.1%) of the included studies have at least 1 author with BPS certification in a nonpsychiatric area and/or formal advanced training in clinical pharmacy practice. In 24 (37.5%) of the included studies, there is no evidence of BPS certification or other advanced clinical pharmacy practice training among the authors.

Discussion

This systematic review summarizes areas of impact of psychiatric pharmacists. It extends the findings of Goldstone et al²¹ and others^87-89 by highlighting recent work done by psychiatric pharmacists on patient-level outcomes. Many previous studies^90-92 describe the impact of pharmacist-performed comprehensive medication reviews and medication management services by highlighting only the number of drug-related problems identified or the number of pharmacist-suggested interventions accepted by the treatment team. Although useful, these findings do not measure the impact of the psychiatric pharmacist directly on patient outcomes, such as symptom control, quality of life, or need for hospitalization. Subsequently, justifying broader inclusion of psychiatric pharmacists across care settings and payment for their patient care services is difficult. This review shows that psychiatric pharmacists can improve patient outcomes. Interprofessional collaboration with input into medication prescribing, comprehensive medication review, and patient education have the most evidence supporting the role of psychiatric pharmacists on patient outcomes. This review also illustrates the types of patient-level outcomes that have been studied previously and may provide good examples for future research. A recent survey⁹³ conducted by CPNP suggests that psychiatric pharmacists engage in many innovative practices, but only a minority are tracking any outcomes, and the metrics being collected are varied. To date, the greatest evidence of pharmacists' impact on patient-level outcomes is on improving medication adherence, achieving therapeutic goals, avoiding hospitalizations, and improving medication safety through avoidance of inappropriate medications and management of adverse effects. Future work by psychiatric pharmacists should focus on the impact of their services on these patient-level outcomes with study designs that include pre-post or randomized controlled comparisons, such as those by Hashimoto³⁶ and Mishra.⁴² Use of standardized measurement tools or well-defined assessments of health service use is also recommended, such as those in the work of Harms⁷⁹ and Doyle,⁸⁰ among others.

A broad definition of psychiatric pharmacist is deliberately utilized for this review in order to include as many pharmacists practicing with a focus on CNS medications as possible. Questions remain regarding the degree of training and/or certification necessary for achieving optimal patient-level outcomes when a pharmacist is focused on CNS medication management. Nearly two-thirds of the included studies have an author with a BPS certification. Just less than one-third of the studies included in this review have 1 or more BCPP authors. In addition, nearly one-third of the included studies have at least 1 author with board certification in another area, most commonly BCACP. This means that these studies have authors who are certified to manage patients with multiple comorbid conditions and complex medication regimens. Many of them may have had brief additional training in psychiatric and neurologic disorders as part of their certification preparation.^12,13 One such study by Ammerman and colleagues,⁵³ all of whose authors have 1 or more nonpsychiatric board certifications, do not find statistically significant differences in rates of deprescribing of psychotropic medications despite significant rates of deprescribing of other medication classes. Perhaps inclusion of a BCPP with enhanced expertise in evaluation of psychotropic medications might have led to a statistically significant rate of deprescribing of those medications as well. In the remaining 24 studies, there was no evidence of board certification or enhanced formal clinical training among the authors. This may signify that positive patient-level outcomes may be realized by inclusion of pharmacists without specialized certification. However, 8 of these studies specifically include statements regarding additional, brief, focused psychiatric/neurologic training provided to pharmacists interacting with patients in the studies. Although no direct comparisons of patient-level outcomes associated with different levels of pharmacist training/certification are found in the literature, this review appears to suggest that additional training in psychiatry/neurology beyond that included with typical pharmacy degree training is the standard in the majority of published work in which patient-level outcomes are impacted.

This review should be viewed with some limitations in mind. Because only studies describing patient-level outcomes associated with psychiatric pharmacist–provided interventions/activities are included, additional areas of pharmacist impact, such as receipt of referrals, economic impacts to health systems, or provision of drug information, are not assessed. In addition, it is possible that the level of training or psychiatric/neurologic practice experience of some authors and pharmacists associated with the included studies is not accurately characterized as this information was difficult to locate in some cases and was only based on the BPS database²³ at the time of this review, not at the time the pharmacists were carrying out their work or when each article was written. Only a selection of neurologic conditions that are most pertinent to use of CNS medications are included, and thus, we cannot comment on pharmacists' impact in areas such as multiple sclerosis, stroke, or pain or on the neurologic pharmacist specialty as a stand-alone area. Finally, the number of large, well-designed trials is relatively small, and those that have been published are heterogeneous in their methods, precluding meta-analysis.

Conclusion

Pharmacists who focus on the management of CNS medications positively impact patients with psychiatric and neurologic disorders. The majority of studies that assess the impact of psychiatric pharmacists on patient-level outcomes show reductions in emergency department visits and hospitalizations, an improvement in medication adherence, and an increase in patients meeting therapeutic goals and disease control. It is standard for pharmacists who impact patient care in these areas to have additional training in psychiatric and/or neurologic disorders and treatments. In the future, psychiatric pharmacists who are designing and delivering new or innovative services should focus on capturing patient-level outcomes.